Thursday, July 23, 2009

Obesity, Role Models, and Ignorance

In my column for FindLaw this week, I discuss a recent case in which the South Carolina Department of Social Services accused a mother, Jerri Gray, of child neglect and arrested her because her 14-year-old son, Alexander Draper, weighed 555 pounds. The column is critical of the government's decision to treat Gray as a criminal, in the light of what we in the United States generally eat and feed our children at home and what the government feeds them in the public schools. One could say that with school lunches as a model, it is not surprising that we have shockingly high and increasing rates of obesity (among adults and children) and the typical illnesses of affluence, including cardiovascular disease, cancer, and diabetes.

In this post, I want to focus on a related set of questions that a pediatrician raised in a Science Times article (entitled "When Weight Is the Issue, Doctors Struggle Too") this week: "How on earth ... am I supposed to give sound nutritional advice when all they have to do is look at me to see that I don't follow it very well myself? .... And ... how am I supposed to help stem the so-called epidemic of childhood obesity when not a week goes by that I don't break my own resolutions?"

This pediatrician, Perri Klass, M.D., discusses the pros and the cons of having an overweight doctor advising overweight patients. On the one hand, the doctor understands her patients' challenges better than a person who has never had to struggle with her weight (like an AA sponsor, perhaps). On the other, "you could argue that when the doctor gives advice she obviously finds difficult to follow, there's an underlying -- and undermining -- complicit wink: Now that I've told you about healthy eating, let's have a cookie together -- we'll change our habits tomorrow!"

In some ways, the overweight pediatrician is a little like the government condemning a mother for her son's obesity while filling school cafeterias with spaghetti and meatballs, macaroni and cheese, and gallons of milk. Actions speak louder than words.

Am I proposing that only thin people practice medicine? No. But I do think it would be helpful if medical schools educated doctors about good nutrition -- their own and their patients' -- given how much illness is directly linked to diet. Instead, we see hospitals serving patients -- even cardiac patients -- the sorts of food that contribute to their odds of remaining ill. The most healthy diet -- one that consists primarily or exclusively of whole, plant-based, food -- is virtually impossible to obtain in the hospital. If it were not so sad, it would be funny to recount the stories of vegan hospital patients who have tried repeatedly but in vain to avoid being served a breakfast of eggs, sausage, and French Toast.

The writer of the Science Times article recounts another, sometimes-overweight doctor's statement that "'[t]he advice we're supposed to give in pediatric clinic, it boils down to "Eat less, exercise more."'" Though the part about exercising more is good advice, the part about eating "less" is inadequate, at best. Telling a child or her parents that the child should eat "less" does nothing to address the hunger pangs that anyone will feel when she reduces the amount that she eats. If one has to feel hunger to lose weight, moreover, then the odds of remaining svelte diminish substantially. A campaign recommending that children "abstain" from eating is, in other words, no more likely to be successful than the campaign to get teens to abstain from sex has been.

Rather than telling people to starve themselves to become thin (and then hospitalizing the adolescents who take the message to heart and become anorexic), doctors could achieve much greater success by telling parents and their children to eat "differently" rather than "less." Numerous studies have found that obesity rates are much lower in vegans than in people who eat animal products. One of the apparent reasons for this difference is that plant foods (at least whole plant foods) contain fiber, which produces feelings of fullness without adding calories. Fiber also plays a role in mediating the speed of digestion, which can reduce the craving to binge. Animal flesh and products contain no fiber.

By following and recommending a healthful, vegan diet, then, a doctor will not need to direct children to refrain from eating when they feel hungry. Perhaps the doctors struggling to control their own and their patients' respective weights might consider the possibility that ignorance about nutrition -- rather than a lack of willpower -- is the real culprit.

15 comments:

I think it's a bit presumptuous to assume that medical schools DON'T teach good nutrition. If a doctor writes that her advice to patients "boils down to 'eat less' etc." that doesn't mean the doctor is advocating anorexia, the doctor's merely summarizing her actual advice. And in fact weight loss does, in sum, depend upon calorie restriction, whether it means eating more fiber-rich foods as opposed to processed junk food.

The problem, as you mentioned in your blog post, is access. If a hospital cafeteria doesn't provide healthy options, that's not a problem of medical education; that's a problem with hospital administration and budgeting. When a "sometimes-overweight" doctor is 36 hours on call, tired, and doesn't have the energy to plan the perfect health-food diet, and resorts to vending machines in the hospital cafeteria, that doesn't mean she or he wasn't educated on proper nutrition. It just means that the doctor sympathizes with her busy patients and realizes that proper nutrition is not merely about education, but about a change in lifestyle that is difficult to stimulate.

Thanks, bluewords, for your comment. I would presume that doctors are not learning much about nutrition (and I agree with your suggestion that access can be as important as knowledge). Medical schools, however, provide very little instruction about nutrition, and this is evident in the dietary suggestions I have personally heard from highly-regarded physicians -- one told me when I was pregnant that I should eat lots of ice-cream, and another insisted that I give my daughter hamburgers to increase her iron (he didn't apologize when spinach and broccoli swiftly did the trick). Doctors who do know about nutrition have had to educate themselves.

I'm curious about your statement that "Medical schools, however, provide very little instruction about nutrition." I can only speak for my own medical school (which provided a separate course on Nutrition, following our core Biochemistry class), as well as the education of friends at other medical schools, but they all know the basics of good nutrition. If several individual doctors have forgotten their training because they don't use it daily, or because their medical education was decades ago, that doesn't translate to medical schools neglecting to teach nutrition today.

Bluewords,If a medical school had a mandatory course on anesthesia where in the principal technique taught was the rubber mallet head strike, would you suggest that having such a class and calling it "basics of anesthesia" would mean that such a school (which, by definition, has a course on Anesthetic Technique) was a school that was teaching its students about good anesthesia?

If so, fine, then we can all at least understand and evaluate the claim. If not, can I at least suggest that a Medical School class called "Nutrition" that teaches the importance of eating meat and eating and drinking dairy is, in fact, not a school teaching good nutrition?

A lot, although not all, of the obesity problem relates to social and cultural differences. When I was running for office, I asked someone what the major issue in their neighborhood was. There's nowhere to buy fresh food, they said. Why don't you just go to the grocery and buy it, I asked? There's no grocery, they explained, only fast-food outlets. I agree that doctors should do a better job, but it won't help if people get home and the only place to eat is McDonalds.

There's also a socio-economic component to diet. Many studies have concluded that healthier eating is typically more expensive (at least in the context of grocery purchases). It turns out that the nastiest stuff -- sugar, fat, etc. -- also turns out to be the cheapest to produce. Of course, part of that is the result of ill-planned government subsidies.

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"One could say that with school lunches as a model, it is not surprising that we have shockingly high and increasing rates of obesity (among adults and children) and the typical illnesses of affluence, including cardiovascular disease, cancer, and diabetes." - Sherry F. Colb

It is the responsibility of the parent to provide her child with a proper diet. If food in school is that bad, then why not prepare the kid's lunch at home and let her kid take it to school in a lunch box?Parents should also be aware of the dangers of having excess fat and let the child know that obesity can lead to cardiovascular disease, diabetes, and stroke.

Even if one thinks that it's okay for the government to order everyone to see the doctor, an order to exercise does appear to go to far. It looks a lot like conscription, which, if justified in wartime, is still extraordinary. Further, it is not clear how a mandatory exercise regime could possibly be enforced absent something like Orwellian surveillance.